Clinical Problem Solving I James Luker

Patient Demographics 48 years old African American female College level medical education Unemployed Lives with family

Patient Diagnosis Complex migraine headaches Conversion disorder Depression Anxiety GERD Morbid Obesity

Patient History Admitted to ER with c/o headache, LLE weakness, LLE numbness/tingling Evaluated and d/c at another hospital one day PTA No history of falls Symptoms started one week PTA Admitted/evaluated by neuro/psych for similar symptoms twice two years ago, dx of conversion disorder given at that time Started treatment with home health PT and Topamax/Lexapro at this time Topamax – Antiseizure/antimigraine Lexapro - SSRI

PT Exam Findings Strength: 5/5 throughout with exception of LLE LLE MMT L hip flex 2+ L knee flex/ext 2- L ankle DF/PF 2 Strength: 5/5 throughout with exception of LLE ROM: PROM WFL throughout, AROM generally decreased in LLE Neuro: A&Ox4, impaired LT sensation below L knee, coordination WFL Mobility: Independent with all bed mobility, CGAx1 sit-to-stand/stand-to- sit Ambulation: CGAx1 for ambulation 200ft total, L foot drop, widened BOS, decreased pace, decreased step clearance

PT Exam Findings Cont. Stairs: CGAx1 for 15 steps up/down, step-through using rail on R, lead descent with RLE bearing full weight on LLE Balance: Sitting balance intact, standing balance impaired – good static, fair dynamic Tinetti test: Total score 19/28, (<19 = high fall risk, 19-24 = medium fall risk, 25-28 = low fall risk) Pain: 6/10 headache pain Activity tolerance: WNL

Patient Prognosis Rehab potential considered to be good Initial deficits in gait/strength improved rapidly Past care episodes for similar symptoms support conversion disorder dx and good prognosis for full recovery Discharge to home recommended

PT Goals Pt will transfer from bed to chair/chair to bed with modified independence using LRD within 7 days Pt will perform sit to stand independently within 7 days Pt will ambulate 400ft with modified independence using LRD within 7 days Pt will ascend/descend 15 stairs with modified independence (single handrail) within 7 days

Patient Interventions Education Good prognosis for recovery/resolution of symptoms Stress reduction/role of stress in symptom onset Benefits of exercise Gait training Verbal cueing to correct deviations, promote self- awareness Stair training

Treatment Outcomes Strength Gait LLE strength not re-tested Sufficient for ambulation/stairs during treatment compared to baseline of 2- to 2+ throughout LLE during evaluation Gait Deviations during initial ambulation improved markedly over the course of one treatment session Near complete resolution of gait deviations by end of first treatment session

Clinical Question For my 48 year old female patient with conversion disorder, what are the most important prognostic factors for positive long-term outcomes?

Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms n=73 patients 35 Female, 38 Male Mean ages 35 (Female) and 38(Male) Hospital discharge summaries reviewed for initial data Follow-up conducted after 5-7 years Semi-structured interview assessing evolution of symptoms, occurrence of other symptoms, utilization of medical services Schedule for affective disorders and schizophrenia (SADS) completed Chart review conducted Physical re-assessment by neurologist

Prognostic Factors Outcome Odds ratio (95% CI) P-value Symptoms present <1 year PTA + .11 (.02-.67) .018 Comorbid SADS disorder 7.34 (1.29-42.28) .025 Change in marital status during follow-up period 33.66 (2.52 to 444.61) .008 Received financial benefits at time of admission - .15 (.027-.84) .03 Pending litigation at time of admission .09 (.01-1.18) .066 A low n may have contributed to some of these numbers. Pending litigation has a CI including 1 and a p value >.05 indicating not significant.

Study Limitations 12% subjects lost to attrition Specific study setting (neurological teaching hospital) limits generalizability Severity of cases may be biased, less severe cases underrepresented

Psychogenic Tremor: Long-Term Outcome n=127 patients with psychogenic tremor 92 Female, 35 Male Mean age at initial evaluation 43.7 years Verbal interview/chart review used to collect data Follow-up conducted after mean of 3.4 years McMaster Health Index Questionnaire for QOL Patient-rated overall condition compared to baseline – “better vs. same/worse” Follow-up data collection performed by 1 reviewer.

Prognostic factors Outcome Spearman’s Rho P-value Perceived effective treatment by the physician + .54 .0001 Presence of anxiety .31 .007 Elimination of stressor(s) .01 Complying with instructions to follow-up with other physicians/therapists .29 Specific medication .26 .03 Dissatisfaction with the physician - .25 Weaker physical health .24 .07 Longer duration of PMD symptoms .22 .06 History of smoking .21

Study Limitations Retrospective study design Majority of patients lost before follow-up Specific focus on psychogenic tremor

My Patient Positive prognostic factors Negative prognostic factors Perceived treatment as effective Comorbid SADS disorder/Presence of anxiety Short duration of symptoms during current episode Negative prognostic factors Past history of conversion disorder symptoms

References https://www.ncbi.nlm.nih.gov/pmc/articles/PMC28460/ https://www.researchgate.net/publication/6967652_Psychogenic_Tremor_Lon g-Term_Outcome